Provider Demographics
NPI:1306031018
Name:MOORE, MICHAEL KAY (COTA)
Entity type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:KAY
Last Name:MOORE
Suffix:
Gender:M
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4155 CR 3908
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:75766
Mailing Address - Country:US
Mailing Address - Phone:903-586-6990
Mailing Address - Fax:
Practice Address - Street 1:4155 CR 3908
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:TX
Practice Address - Zip Code:75766
Practice Address - Country:US
Practice Address - Phone:903-586-6990
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-06
Last Update Date:2007-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX209911225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist